Failure to Notify Physician and Family After Resident Change in Condition
Penalty
Summary
Facility staff failed to notify residents' representatives and/or physicians after significant changes in condition for three out of five sampled residents. For one resident with severe cognitive impairment, staff did not document notification to the physician or family after two separate falls, and the family later reported not being informed about the fall or subsequent hospital transfer. Progress notes also indicated the family expressed concerns about lack of communication regarding one of the falls during a care plan meeting. Another resident, assessed as cognitively intact, experienced a fall, but there was no documentation that the physician or family were notified. Event reports and progress notes for these incidents lacked evidence of required notifications. A third resident experienced a significant weight loss of 7.62% over a short period, but the medical record did not show that the family or representative was notified of this change. Interviews with staff, including an LPN, the administrator, and the DON, confirmed that the facility's protocol is to notify the physician and responsible party after a change in condition, but the facility was unable to provide a policy for this process. The facility census at the time was 80.